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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> w = (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT A <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> er r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County O finance No.1862 and the rules and regulations of the San Joaquin Local Health District. ' <br /> Exact Site Addre 24 City/Town <br /> Owner's'Namep Phone ��{ <br /> ' <br /> �`f - <br /> Address City <br /> Contractor's Name `" - ` License# �' Business Phone <br /> Contractor's Address Ir �.: <br /> '°'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes -. No <br /> TYP OF WORK (CHECK): NEW WELL❑ pEEPEN ElAECONDITIQN❑ DESTRUCTIONN❑ <br /> WDLL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ t <br /> kSLCMTANCAEENTE TO NEAREST: Septic Tank!l Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit _ ._ Other <br /> Property Line Private Domestic Well Public Domestic Well t <br /> XTENDED USE "el TYPE OF WELL <br /> ©/INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ,1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �. } <br /> ❑ DISPOSAL ❑ OTHER Other Information y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1l <br /> 4 PUMP INSTALLATION:� � Contractor <br /> `� * s Type of Pump H.P,j � ! <br /> t <br /> 'PUMP REPLACEMENT:)- , ❑ State Work Done._... �),` E r <br /> PUMP REPAIR: a4 ❑. State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ;� ` 5 # Approximate Depth F <br /> Describe Material and Procedure. s_3 ` 7 <br /> .l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County- <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.,----' <br /> Home owner or licensed agent's signature certifies the following;_I.cer4ify that in the performance of the work for which this permit <br /> =- is issued�i'sTlall not employ any pensiwin-such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> j permit is issued, I shall employ persons subjectto workman's compensation laws of California." <br /> I will call or a Groot-in pection prior to grouting and a final inspection. 1 <br /> Signed i Title: Date:-*-:?--'1--7.-c; <br /> (Draw Plot Plan On Reverse Side) 1i i <br /> - l <br /> FOR�DEPA TMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: �- <br /> Phase III GroutInsp <br /> Inspection. Phas al Inspection <br /> Inspection By Date `^�- v ' -;q 4 Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY © PER UNIT El PER SITE ❑'EACH 'January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> CE. $ REMIT <br /> BILLING REMITTANCE-BASE EXPLANATION � � AMOUNT DUE. - CHECKED4 <br /> DATE 7 DAT•li`� REMITTED AMOUNT <br /> FEE � r ^' '` ~. `C• } <br /> LESS - - - •,a. rte: ` i <br /> PRORATION \ t <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Re ved.by - Date Receipt No. P rmit No. Issuance Date Mailed Delivered <br /> ..CAT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 115011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />